Basic Nursing Skills for CNAs

Vital signs are objective measurements of how a resident's body is functioning, and on the NNAAP exam you will almost certainly be asked to take and accurately record at least one of them. The four classic vitals are temperature, pulse, respirations, and blood pressure (often abbreviated TPR and BP). Before you begin, wash your hands, identify the resident, explain the procedure, and provide privacy. Always wait at least fifteen minutes after the resident has eaten, smoked, exercised, or had hot or cold fluids before taking an oral temperature or pulse, because all of these can alter the reading.

Temperature is taken by one of four routes, and each has its own normal range. An oral reading is typical at 97.6 to 99.6 degrees Fahrenheit (average 98.6 F). Axillary readings run about one degree lower than oral (96.6 to 98.6 F), while rectal and tympanic readings run about one degree higher (98.6 to 100.6 F). Rectal temperatures are the most accurate but are reserved for residents who cannot safely hold an oral probe, and they require lubricant and the Sims' position. Always note the route used on the chart.

Pulse is most often counted at the radial artery on the thumb side of the wrist. Place your first two fingers (never your thumb, which has its own pulse) lightly over the artery and count for thirty seconds, multiplying by two for a regular rhythm. If the pulse is irregular, weak, or unusually fast or slow, count for a full sixty seconds. The apical pulse, taken with a stethoscope at the fifth intercostal space on the left side of the chest, is always counted for a full minute and is required before giving certain heart medications.

Respirations are counted while the resident is unaware, because conscious breathing changes the rate. A common trick is to leave your fingers on the wrist as if still counting the pulse and then watch the chest rise. One rise plus one fall equals one respiration; count for thirty seconds and multiply by two, or count a full minute if breathing is irregular. Blood pressure is measured manually with a sphygmomanometer and stethoscope placed over the brachial artery. The top number (systolic) is the pressure when the heart contracts, and the bottom number (diastolic) is the pressure when the heart rests. Report any reading outside the resident's baseline to the nurse immediately.

Height and weight are recorded on admission and then routinely throughout a resident's stay, because weight is one of the clearest indicators of nutrition, hydration, and disease progression. A sudden gain of two or more pounds in a day, or five pounds in a week, often signals fluid retention from heart failure or kidney problems, while unexplained loss may point to dehydration, infection, or inadequate intake. As a CNA you are responsible for accurate technique and consistent conditions so that small but clinically important changes are not missed.

For an ambulatory resident, use a standing balance or digital scale. Have them void first, remove shoes and heavy outerwear, and step onto the center of the platform with weight evenly distributed. Read the weight once the scale stabilizes. To measure height, ask the resident to stand straight with heels together and look forward; lower the height rod gently to the top of the head and read at eye level. Residents who cannot stand safely should be weighed on a chair scale or bed (sling) scale, following the same principle of starting from a calibrated zero.

Daily weights, when ordered, must be done at the same time each day, on the same scale, with the resident wearing similar clothing, and after the first void. Most U.S. facilities record weight in pounds, but you will frequently see kilograms on metric scales and in medication dosing; the quick conversion is 1 kg equals 2.2 lb. Document the value, the scale used, and any factors that might affect accuracy (such as a cast or refusal to remove a robe) so the nurse can interpret the trend correctly.

Intake and output, written as I&O, is the running tally of every fluid that goes into and out of a resident over a defined period, usually each shift and then summed for 24 hours. It is one of the most important tools for spotting dehydration, fluid overload, and kidney problems, and it is a frequent skill on the NNAAP exam. All measurements are recorded in milliliters (mL), and the gold standard conversion every CNA must memorize is 1 fluid ounce equals 30 mL. So an 8 oz cup of juice equals 240 mL, and a 4 oz gelatin cup equals 120 mL.

Intake includes anything liquid at room temperature: water, coffee, tea, juice, milk, soup broth, ice chips (counted as half their volume because ice is more compact than water), gelatin, ice cream, popsicles, IV fluids, tube feedings, and water used to flush a feeding tube. Solid foods are not counted, even if they contain water. Encourage and offer fluids frequently, document the exact amount the resident actually drank (not what was served), and subtract any liquid left in the cup.

Output includes urine, emesis (vomit), liquid stool, wound drainage, blood loss, and contents of suction or surgical drains. Pour the fluid into a graduate (calibrated measuring container), set it on a flat surface, and read the level at eye level to avoid parallax error. Always wear gloves, and never estimate; if a resident is incontinent and the volume cannot be measured, document it as such. At the end of the shift add up totals and report any significant imbalance, particularly urine output below 30 mL per hour, which suggests poor kidney perfusion.

Residents who are bedbound or have limited mobility must be repositioned at least every 2 hours, day and night, to prevent pressure injuries (formerly called bedsores), maintain circulation, and prevent contractures. The clock starts at the last documented turn, and you must record the new position each time. Common bony areas to inspect and offload include the sacrum, heels, hips, elbows, shoulders, and the back of the head. Use pillows to support the head, back, and between the knees, and always keep the bed in the lowest position with the wheels locked when you leave.

Each named position serves a clinical purpose. Supine is flat on the back, used for rest and many physical exams. Prone is face down, rarely used in elderly residents because it stresses the spine and breathing. Lateral is lying on the side, ideal for relieving pressure on the sacrum. Sims' is a left-side-lying position with the upper knee flexed forward, used for rectal procedures and enemas. Fowler's is sitting with the head of the bed at 45 to 60 degrees, used for eating and breathing comfort, while semi-Fowler's is the same position at 30 to 45 degrees and high Fowler's is 60 to 90 degrees.

Body mechanics protect you as much as the resident. The principles are simple but life-saving for your back. Keep your feet shoulder-width apart to create a wide base of support, bend at the hips and knees rather than the waist, hold the load close to your body, push or pull rather than lift when possible, and always turn with your feet rather than twisting at the waist. Never attempt a heavy or awkward lift alone; use the gait belt, a slide sheet, a mechanical lift, or a second staff member. Back injuries are the leading cause of nursing assistants leaving the field, and most are preventable.

A bed-to-chair transfer is one of the most commonly tested NNAAP skills, and the gait belt is the safety tool at the center of it. Begin by raising the head of the bed and dangling the resident's legs to prevent orthostatic hypotension. Apply the gait belt over clothing, snug enough that you can slip only your fingers underneath (not your whole hand), and never apply it directly over bare skin, surgical sites, or feeding tubes. Position the chair on the resident's stronger side at a slight angle and lock all wheels on both the bed and the chair before moving.

For a stand-pivot transfer, stand directly in front of the resident, block their knees with your knees (knee-to-knee or toe-to-toe stabilization is an NNAAP requirement), and grasp the gait belt with both hands underhand at the sides. On a count of three, have the resident push up from the bed using the armrests, straighten with you, pivot in small steps, and lower slowly into the chair. Keep your own back straight and lift with your legs. Never pull on the resident's arms, neck, or under the armpits.

Ambulation with a gait belt follows the same principles. Walk slightly behind and to the weaker side of the resident, holding the belt with an underhand grip. The NNAAP skill typically requires walking the resident a measured distance of about 10 feet and then safely returning them to a seat. With a walker, all four legs (or two legs and two wheels) should touch the floor before the resident steps forward. With a cane, the cane is held on the strong side and advances first, followed by the weaker leg, then the stronger leg.

For residents who cannot bear weight, a mechanical lift (often called a Hoyer lift) is required. Two staff members are needed: one to operate the lift and one to guide the sling. Center the sling under the resident, attach the straps to the correct color-coded hooks, raise just enough to clear the bed, and move slowly to the chair. Never leave a resident suspended unattended, and always lock the chair wheels before lowering.

Range of motion exercises move each joint through its normal arc of motion to prevent contractures, maintain joint flexibility, improve circulation, and preserve muscle tone in residents with limited mobility. ROM comes in three forms: active ROM, performed by the resident independently; active-assistive ROM, where the resident does what they can and the CNA helps with the rest; and passive ROM (PROM), where the CNA moves the joint while the resident is fully relaxed. Passive ROM is the most commonly delegated form to CNAs and is often done during the morning bath, when joints are warm and muscles are relaxed.

ROM exercises are typically performed at least twice a day, with each joint moved through its full range three to five times. Always work from the head down or from one side to the other in a consistent pattern, and support the joint both above and below as you move it. Move slowly, smoothly, and only to the point of slight resistance, never forcing through pain. Stop and report immediately if the resident complains of pain, if you feel grinding, or if a joint will not move as far as it did yesterday.

The basic joint movements you must recognize for the NNAAP exam include flexion (bending a joint to decrease the angle), extension (straightening a joint to increase the angle), abduction (moving a limb away from the midline of the body), adduction (moving a limb toward the midline), rotation (turning a joint on its axis, as in turning the head), pronation (palm down), and supination (palm up). The skill is most often tested on the shoulder, elbow, wrist, fingers, hip, knee, and ankle. Keep the resident covered for privacy and warmth, and only expose one limb at a time.